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Family Voices of New Jersey copyright 20091 Health Care Advocacy in the Managed Care Environment Medically Necessary Services; Primary Care Providers;

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Presentation on theme: "Family Voices of New Jersey copyright 20091 Health Care Advocacy in the Managed Care Environment Medically Necessary Services; Primary Care Providers;"— Presentation transcript:

1 Family Voices of New Jersey copyright Health Care Advocacy in the Managed Care Environment Medically Necessary Services; Primary Care Providers; Specialty Care; Covered Services; Costs; Choosing Health Coverage and Providers; Prescription Drugs Presented by Beverly Roberts, Arc of New Jersey, Director, Mainstreaming Medical Care Project Hosted by Family Voices-NJ/ Family-to-Family Health Information Resource Center of the Statewide Parent Advocacy Network April 1, 2009

2 Family Voices of New Jersey copyright Medicaid Managed Care – workshop objectives What services are covered Useful terminology Selecting a plan or a provider Working with your providers Advocating for your child Dispute resolution Resources for support and information Find highlighted words in “Important Terms” handout, Fact sheet # 7, at

3 Family Voices of New Jersey copyright Managed care When it works well, Medicaid managed care can provide a comprehensive approach to providing and paying for high-quality medically- necessary health care services - from routine to emergency - within a coordinated system - in a cost-effective manner

4 Family Voices of New Jersey copyright Health Maintenance Organizations (HMOs) The health plans that provide the Benefits Package for the Medicaid managed care system in New Jersey AmeriChoice Amerigroup Community Care Horizon NJ Health Health Net University Health Plans

5 Family Voices of New Jersey copyright Medicaid managed care and NJ FamilyCare The original name of the program was Medicaid managed care. The Medicaid office now calls the program “NJ FamilyCare.” NJ FamilyCare includes the Medicaid population as well as higher income enrollees. In these slides, the term Medicaid managed care or Medicaid HMOs will be used.

6 Family Voices of New Jersey copyright The Basics of HMOs Medicaid HMOs provide coverage for enrollees in a geographical area for a prepaid, fixed capitation rate. The fee is paid by Medicaid – no cost to the enrollees as long as they see providers in the HMO’s network.

7 Family Voices of New Jersey copyright “Hallmarks” of Managed Care Using specific providers Not relying on the emergency room for primary care services Authorizing of specialty care and referrals …from The Boggs Center – University Center of Excellence

8 Family Voices of New Jersey copyright Characteristics of Medicaid managed care Health Benefits Coordinator (HBC) handles enrollment into HMO HMO ID card HMO Member handbook HMO Primary Care Provider (PCP) HMO Care Manager HMO Individual Health Care Plan (IHCP) HMO Provider Network (provider directory) Referral Prior authorization Emergency vs. urgent vs. routine care

9 Family Voices of New Jersey copyright Covered Services HMO benefits package Primary & specialty care Preventive health care & counseling Health promotion EPSDT (Early Periodic Screening, Diagnosis, & Treatment) Emergency Medical care Inpatient hospital care (acute, rehab, specialty) Outpatient hospital Laboratory Radiology Audiology

10 Family Voices of New Jersey copyright Covered Services HMO benefits package Inpatient rehabilitation Podiatrist Chiropractor Optometrist Optical appliances Hearing aid services Home health (with limits) Hospice Durable Medical equipment & medical supplies

11 Family Voices of New Jersey copyright Covered Services HMO benefits package Prosthetics & orthotics (including shoes) Dental Organ Transplants Post-acute care Mental health/substance abuse for DDD clients (non-DDD clients continue to receive mental health services on a fee- for-service basis as they did in the past)

12 Family Voices of New Jersey copyright Covered Services HMO benefits package Includes mental health & substance abuse services for DDD clients (these services are carved out for everyone else) Include some transportation HMOs may offer participants additional services beyond those Medicaid entitles them to

13 Family Voices of New Jersey copyright Services that are “Carved Out” HMO “carve out” services, which are still paid for by Medicaid fee-for- service: PT, OT, and Speech therapy Some transportation Mental health & substance abuse services for non-DDD clients Medication for special needs enrollees (in aged, blind and disabled category) Home health care

14 Family Voices of New Jersey copyright Care Management – Very Important Service! The HMO will assign a Care Manager. ALL children with special healthcare needs in NJ Medicaid Managed Care are entitled to a Care Manager! Usually a nurse or social worker The Care manager helps coordinate your child’s care S/he is the first person to contact with a question, or concern with your child’s health coverage Request a care manager if not automatically assigned to one “Member service” staff are very different from care managers.

15 Family Voices of New Jersey copyright Costs Medicaid entitles beneficiaries to free health care. Always bring your HMO ID card to all visits. Also bring the plastic Medicaid Identification card Enrollees who follow correct HMO procedures should never receive a bill. (If you don’t follow procedures you may be held liable for bills.)

16 Family Voices of New Jersey copyright Balance Billing Is Not Permitted Medicaid enrollees who follow the rules of the HMO should never receive a bill. However, sometimes bills are sent in error by a hospital or doctor. If this happens, contact HMO care manager and ask her to fix the problem. Don’t ignore any bills that you receive!

17 Family Voices of New Jersey copyright Using Medicaid Managed Care Call the HBC to enroll in an HMO Read your HMO member handbook Select & work with your PCP (Primary care provider) Get referrals for other services Work with your care manager Use network providers Use emergency rooms only for emergencies (prudent layperson decision) If you think your child needs emergency care, go to the ER!

18 Family Voices of New Jersey copyright Exemption from Medicaid managed care The exemption process is now hassle-free! If your child’s health care needs are being met from Medicaid fee-for-service, you can request an exemption. Call the Health Benefits Coordinator at to request. All requests are honored.

19 Family Voices of New Jersey copyright Choosing a Medicaid HMO plan Which Medicaid HMO is best for your child? Are the doctors you want for your child in this HMO? Your child’s hospital? Does the HMO provide services in convenient locations – not just PCP, but also laboratories for blood work, medical equipment, specialists? Are your child’s specialty clinics in the network? If not, will the HMO be willing to refer your child outside the network to these specialty clinics? What dental services are provided? Are they accessible? Are your child’s current durable medical equipment suppliers in the HMO’s network? If not, how will you access them? Do the providers speak your language or have interpreters?

20 Family Voices of New Jersey copyright Choosing an HMO Which Medicaid HMO is best for your child? Which HMO provider network(s) are your child’s most important current providers in? Ask your providers or the HBC. Some of your providers may be able to join the provider network for the HMO that looks best to you. Ask the HMO’s member services. Choose the plan that has your most important current providers or that meets most of your requirements. Remember that you can switch to a different Medicaid HMO if you need to. There is no “lock in.” If necessary, you can request an exemption and return to regular Medicaid.

21 Family Voices of New Jersey copyright Choosing…providers Who is the best PCP for your child? Does the provider have experience working with families of children with special health care needs? Has the provider worked with children with your child’s special needs before? Who will see you when he/she’s not available? Is the office close to your home? Convenient hours? Are the office & exam rooms accessible to you? Does this provider speak your language or sign? Does the provider offer access to the specialty services your child needs? What hospitals is the provider affiliated with?.

22 Family Voices of New Jersey copyright Hospitals and Managed Care Keep in mind that the HMO network includes not only doctors but also hospitals, labs, durable medical equipment providers, etc.

23 Family Voices of New Jersey copyright Once you’ve chosen… Read your Member Handbook carefully! Identify important people and phone #s and post them by your phone Be sure you learn how to reach help after hours! Keep records of all provider contacts in case misunderstandings arise

24 Family Voices of New Jersey copyright After you’ve chosen, you may still change… …HMOs if you have major problems. Call the HBC to process changes ( ) Changes take time – between 14 and 45 days or more …PCPs if you are not satisfied with your first selection. Call HMO member services, or talk to your care manager for information on selecting a new PCP You can also disenroll from the HMO and return to Medicaid fee-for service by calling the HBC

25 Family Voices of New Jersey copyright Medically Necessary Services are services required to: diagnose or prevent an illness, injury or condition treat an illness, injury, or condition keep condition from getting worse lessen pain or severity of condition help improve condition restore lost skills (rehabilitation)

26 Family Voices of New Jersey copyright Medically Necessary: requirements for children The service is appropriate for the age & health status of the child; the service will aid overall physical & mental growth & development; and/or the service will assist in achieving or maintaining functional capacity.

27 Family Voices of New Jersey copyright Dealing with Emergencies If you, as a “prudent layperson”, decide that your child has an emergency medical condition, the HMO pays for the hospital Emergency Room treatment without requiring a referral or pre-approval. Call 911 or go to nearest emergency room DON’T use emergency room for routine care!

28 Family Voices of New Jersey copyright Dealing with Urgent Care Call HMO 24-hour toll-free number if your child needs urgent care (attention within 24 hours but not emergency) Your PCP will provide or arrange for urgent care

29 Family Voices of New Jersey copyright Emergency vs. Urgent Care Examples of an emergency: A head injury A possible broken bone Bleeding from an injury that doesn’t clot and might need stitches. Examples of the need for urgent care: Possible ear infection A lingering cough that might be bronchitis

30 Family Voices of New Jersey copyright It helps your providers when You give them all the info they need to give your child the best care You ask questions when you don’t understand You honestly express your concerns You treat them with the same respect you expect them to give you You use resources wisely (e.g. use HMO 24 hour hotline for urgent, not routine, questions) You thank them when you like what they do!

31 Family Voices of New Jersey copyright How to Ask Questions Get member handbooks from each HMO Call member services in each HMO if you have questions Always keep a record of phone calls and correspondence. Make copies of everything! Keep a logbook next to your phone and record the date, name, position/title, and answer to your questions Be persistent, but try to remain polite!

32 Family Voices of New Jersey copyright Expect your PCP to… See to your child’s basic health needs Coordinate medical care, including routine, preventive, urgent, & specialty Make referrals (& standing referrals) Take care of prior authorizations You should keep your PCP informed of contacts with other provider visits, including emergency room visits.

33 Family Voices of New Jersey copyright Expect your care manager to … Have experience with people with special needs May be one of your best (and most under- utilized) troubleshooting resources Coordinate all your child’s services & needs Develop an IHCP with you and your child Help with referrals & locating specialists You should call and ask to talk to your care manager to get a basic care plan started soon after HMO enrollment!

34 Family Voices of New Jersey copyright What about Co-Pays? Currently, there are no co-pays in NJ’s Medicaid managed care system. However, the proposed budget does include co-pays, and we probably won’t know the outcome until June, If NJ’s new budget does include Medicaid co-pays, they would start July 1, 2009.

35 Family Voices of New Jersey copyright Free Services from Community Health Law Project Free 74-page booklet, “To Your Health: Your Consumer Rights in Managed Health Care” explains Managed Care Law in NJ. Booklet covers NJ managed care law in both commercial and Medicaid systems. Provides samples of what to say on the phone or in a complaint/grievance letter. To request the booklet call

36 Family Voices of New Jersey copyright If you have a problem with… A provider, talk to your care manager With your HMO not meeting your child’s needs, call: Managed Health Care Consumer Assistance Program (MHCCAP) Helpline - Hours of operation: Mon. thru Thurs. 9:00 – 5:00; Fri :00 No charge for assistance in resolving the problem Medicaid Managed Care Hotline

37 Family Voices of New Jersey copyright Advocacy An advocate pleads the case of another When you advocate effectively to meet your child’s needs, you may change a whole system to better meet other’s needs When you advocate effectively for all children with special needs, you may help make systems work better for your child and family

38 Family Voices of New Jersey copyright Advocating & Medicaid Managed Care Enlist allies – providers or parent support; take representation to formal hearings Ask your elected officials to support policies that will help children with special health care needs Help your child become a self-advocate at whatever developmental level she’s at You are your child’s best advocate!

39 Family Voices of New Jersey copyright Dispute Resolution To prevent disputes or misunderstandings: Learn your Medicaid managed care rights and responsibilities from your member handbook If there is anything you don’t understand, ask your PCP, care manager, or HMO member services Try to resolve problems when and where they arise by talking openly with the person(s) involved You can file a complaint, grievance or appeal, or your PCP or another representative can do it for you, with your permission

40 Family Voices of New Jersey copyright Dispute Resolution… If you can’t prevent or immediately resolve a problem to your satisfaction, call HMO care manager or member services and make a complaint. Be specific. If the problem is not resolved in 24 hours, you may register a grievance with your HMO by phone or letter If you are not satisfied with the HMO’s solution, call the state Medicaid hotline or the MHCCAP helpline. Keep records of all contacts!

41 Family Voices of New Jersey copyright Appeals HMO must notify you in writing 10 days before it denies or limits covered services. You may file an appeal of the denial with your HMO. Contact SPAN’s F2F SPAN. Sometimes appeals are resolved easily, but the process can become complicated, so you may want to turn to the Community Health Law Project or Legal Services of New Jersey for advice.

42 Family Voices of New Jersey copyright Appeals – stages Internal (within HMO): two stages 1. With HMO medical director or MD who denied services 2. With physicians not involved in 1 st internal appeal who might care for children like yours External (if internal gives unsatisfactory results) 3. To NJ Dept. of Health and Senior Services to refer appeal to an Independent Utilization Review Organization ($2). IURO reviews case & (if it accepts it) issues a decision to you &/or your PCP, & your HMO.

43 Family Voices of New Jersey copyright Appeals … At each stage, if the HMO continues to deny services, it must inform you in writing within a specified time, giving you reasons for denial and how to proceed to the next stage At any time during the appeals process, you may also request a Medicaid Fair Hearing. Ask for an immediate review in any urgent situation! Keep good records of all interactions.

44 Family Voices of New Jersey copyright Medicaid Fair Hearing Within 90 days of service denial, you can file for a fair hearing Call the Medicaid Hotline at the NJ Department of Human Services At a fair hearing, an impartial judge listens to your position. You can bring witnesses and cross-examine the HMO’s witnesses It’s a good idea to take legal representation to the fair hearing. Call Community Health Law Project or Legal Services of New Jersey.

45 Family Voices of New Jersey copyright Resources for Support and Information Family Voices Resource List: important literature and phone numbers to help you with Medicaid managed care questions (Fact sheet #6) Family Voices Fact Sheets Top resources: Your care manager at your HMO Medicaid managed care hotline Managed Health Care Consumer Assistance Program


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